Abstract
Postpartum depression and exercise
Postpartum depression is a global mental health issue, annually affecting 13 million women worldwide. There can be reluctance from postnatal women to take antidepressants, particularly if they are breastfeeding. It can also be difficult for patients to access psychological therapies, such as cognitive behaviour therapy. A recent systematic review and meta-analysis of international research on postpartum depression showed aerobic exercise to be an effective management option and a potential preventative intervention more generally in postpartum women.
Blamey, R. V., Daley, A. J., & Jolly, K. (2017). Does aerobic exercise reduce postpartum depressive symptoms? a systematic review and meta-analysis. British Journal of General Practice. 67(663): e684–e691. doi: 10.3399/bjgp17X692525
Breastfeeding and endometriosis
One in 10 women of reproductive age in the UK suffer from endometriosis. The cause of endometriosis is unknown and there is no definite cure. Endometriosis can cause symptoms, such as chronic pelvic pain, dysmenorrhea and dyspareunia. A recent prospective cohort study, called the Nurses’ Health Study II that began in 1989, when 116,430 registered nurses aged 25–42 returned a mailed questionnaire on their health and lifestyle. Breastfeeding (any and exclusive breastfeeding) is associated with a lower risk of endometriosis. Women who did not breast feed were at a significantly increased risk of endometriosis compared with women who breastfed for up to 1 year. Current UK policy is to promote exclusive breastfeeding (feeding only breast milk) for the first 6 months. Thereafter, it recommends that breastfeeding should continue for as long as the mother and baby wish, while gradually introducing a more varied diet.
Farland, L. V., Eliassen, H., Tamimi, R., Spiegelman, D., Michels, K., & Missmer, S. (2017). History of breast feeding and risk of incident endometriosis: prospective cohort study. BMJ, 358, j3778. DOI: 10.1136/bmj.j3778
Leukaemia
Leukaemia is the twelfth most common cancer in the UK, with over 9500 people diagnosed each year. However, the charity Leukaemia Care reports that because the symptoms are typically vague and non-specific, people with leukaemia are more likely to be diagnosed following an emergency admission than patients with all other types of cancer. In a survey carried out by the charity on over 2000 people living with the condition in the UK, 9% of respondents put off seeing a GP for over a year despite having symptoms. Leukaemia Care has developed several online training modules in partnership with the RCGP e-Learning team. This course highlights the changing landscape of haematological malignancies in the UK and the importance of early recognition and use of investigations in primary care for early diagnosis.
www.rcgp.org.uk/learning/online-learning/ole/blood-cancer.aspx
Obesity influences rheumatoid arthritis diagnostic tests
A recent study published in Arthritis Care & Research, said fat mass could push up C-reactive protein (CRP) and erythrocyte sedimentation rate levels, and be mistaken for arthritis disease activity. In a study looking at over 2100 patients with rheumatoid arthritis (RA), data was compared with that of the general population. Among women with RA and in the general population, greater body mass index was associated with greater CRP, especially among women with severe obesity. The DAS28 is a measure of disease activity in RA that is used by some rheumatologists in the UK. DAS stands for ‘disease activity score’ and the number 28 refers to the 28 joints that are examined in this assessment. There are a wide range of measures of disease activity, including the erythrocyte sedimentation rate (ESR) and C reactive protein (CRP). These results are then fed into a complex mathematical formula to produce the overall disease activity score. It is therefore better to review trends in inflammatory markers and consider this when next reviewing a patient with RA.
George, M., Giles, J., Katz, P., England, B., Mikuls, T., Michaud, K., …, Baker, J. (2017). The impact of obesity and adiposity on inflammatory markers in patients with rheumatoid arthritis. Arthritis Care and Research. doi: 10.1002/acr.23229
One you campaign
Public Health England (PHE) has launched ‘The Active 10’ app that encourages people to incorporate brisk 10-minute walks into their daily routine to help delay, or reduce their risk of developing serious conditions and early death. The app encourages users to introduce more activity. The app is available free-of-charge and tracks patients’ activity by measuring both walking intensity and activity time rather than just measuring steps completed in a day. It comes as evidence reviewed by PHE shows that people in the UK are 20% less active now than they were in the 1960s, and that adults on average walk 15 miles less a year than two decades ago. Walking for just 10 minutes at a brisk pace every day can reduce risk of early death by 15% and help prevent or delay onset of disability, type 2 diabetes, heart disease, dementia and some cancers.
Try it out in your own surgery. We tried it and failed to do one fast minute in a single busy and long on-call day.
www.gov.uk/government/news/6-million-adults-do-not-do-a-monthly-brisk-10-minute-walk
Cancer
The June 2017 volume of the British Journal of General Practice was a special issue on cancer. Thrombocytosis in people over 40 may be a marker for cancer and this hit the national press. You might want to ask how your practice deals with new guidelines and how we deal with population versus individual risk. One approach might be to use the BMJ Rapid Recommendations articles that aim to translate research into user-friendly advice and decision aids.
Another article highlighted the cancer strategy for England recommendation that GPs prescribe tamoxifen for primary prevention of breast cancer for women at increased risk. I wonder, how many of us are doing this?
bmj.com/rapid-recommendations
Arthroscopy
An expert panel, with patient input, has recommended against arthroscopy for degenerative knee disease. This might have widespread implications for practice.
Siemmieniuk, R., Harris, I., Agoritsas, T., Poolman, R., Brignardello-Petersen, R., Van der Velde, S., …, Kristiansen, A. (2017). Artroscopic surgery for degenerative knee disease: A clinical practice guideline. BMJ, 357(8105), 297–279
Contraception and epilepsy
The risks of epilepsy and of treatment for epilepsy should prompt us to ‘think contraception’ in every consultation with women of child-bearing age who have epilepsy.
A BMJ ten-minute consultation article summarises the evidence, including tables of enzyme-inducing properties and risk of foetal malformation for common antiepileptics.
Gooneratne, I., Wimalaratna, M., Ranaweera, A., & Wimalaratna, S. (2017). Contraception advice for women with epilepsy. BMJ, 357(8105), 280–281
Disease or risk factor?
I belong to the overdiagnosis group at the RCGP. One of our recent topics of discussion has been the onset of treatment for ‘prediabetes’ and a debate about whether this is a disease (for which the arbitrary threshold has just been changed) or a risk factor that should be shared in context with the patient. Professor Martin Marshall has written a BMJ Opinion article on the topic.
Marshall, M. (2017). I’m an uncertainty specialist. BMJ, 357(8105), 282
Exercise and back pain
A 320-participant trial showed that both yoga and physical therapy showed improved physical function in adults with chronic low back pain, when compared with education, maintained at a year after the intervention.
Saper, R., Lemaster, C., Delitto, A., Sherman, K., Herman, P., Sadikova, E., & Culpepper, L. (2017). Yoga, physiotherapy or education for chronic low back pain: A randomised non-inferiority trial. Annals of Internal Medicine, 167(92), 85–94. DOI: 7326/M16-2579
Smoking and mental health
I attended a co-produced session with mental health patients to discuss physical health in people with long-term mental health problems. For me it unpicked the myth that people with mental health problems do not want to talk about their physical health problems, or have the same access to preventative measures as other patients. The South London and Maudsley NHS Foundation Trust has introduced a comprehensive smoke-free policy, including banning smoking on hospital grounds. On admission patients have access to nicotine replacement therapy, and are permitted to use e-cigarettes
Parity for mental health
A British Medical Association investigation has shown that in England, 5876 adults were sent out of area for mental health treatment in 2016–2017 (up from 4213 in 2014–2015). I read this the week before I watched the mental health-focused episode of the Channel 4 series Hospital (based at Imperial College Healthcare NHS Trust), showing the effects on patients and staff of the shortage of acute mental health beds. A member of staff on the series commented that this would not be good enough for a friend or family member. Indeed, and not good enough for anyone.